Health services research in plastic surgery

Plastic surgeons and HSR

Plastic surgeons are increasingly pursuing HSR to understand patient-centered outcomes and implications of enacted policies. As funders focus on quality metrics, surgeons are engaging in research to understand variation in quality. The measurement and improvement of quality occurs with consideration of structure, process and outcome metrics. HSR employs large datasets to study variation, but also consider patient priorities through qualitative research and patient-reported outcome measures (PROMs). An understanding of the methodologies and results of health services research strengthens a plastic surgeon’s practice.

Considering structural root causes

Most HSR studies of inequities have been descriptive, but the key step is identifying the root causes of these inequities to redesign equitable care delivery. Equity can and should be considered in the design of all health services research, as an equity lens can shift focus on population, sampling, and analysis. Even existing descriptive findings should be evaluated for the handling of race in comparisons. Race is a social, not biological, construct; adjusting a model for race ignores the role of structural racism on the outcome. There is not yet an established quantitative methodology to account for historic and current structural disadvantage. Research toward that goal requires broadening the traditional conceptual model for healthcare access and health services research to include the influences of structural disadvantage at all steps ( Fig. 13.1 ). In this initial section we will highlight progress to date to promote further investigation and action. The Neighborhood Atlas project from the University of Wisconsin facilitates the merging of researchers’ datasets with the Area Deprivation Index (ADI). This is a geographic marker of relative socioeconomic disadvantage by incorporating traditional metrics of income, education, and employment. It has been used to evaluate improved risk-adjustment in surgical outcomes and association with likelihood of residential burn injury.

Though established in public health research decades ago, social determinants of surgical outcomes are now an area of active research. Improvement of population health requires consideration of the communities in which patients live. The concept of “spatial justice” as a driver of population health integrates the work of social scientists, urban planners, community residents, and healthcare providers. The systemic changes required to fix historic harms require combined efforts and are not simple fixes. However, improved recognition of the impact of systemic disadvantage on surgical outcomes can assist in risk-adjusting outcomes in the short term.

Taking action toward equitable research and outcomes

Beyond considering the role of structural disadvantage on patient care and outcomes, surgeons must confront the racial inequities in publication. Only 8% of the images in breast surgery research publications depict non-White skin. This presents the opportunity to take action toward equity – whether in publication design or acceptance. For example, a targeted review of the breast reconstruction research facilitated identification of medical mistrust and legislation as areas of focus to mitigate the clear racial disparity. Investigating these areas for action requires an antiracist lens and will provide opportunities for the specialty of plastic surgery to lead the way in equity. Butler et al . applied this consideration to breast reconstruction and identified proposed patient education, legislative, and academic medical institution efforts to target contributing factors. For example, a Philadelphia-based effort worked in the community to improve understanding and knowledge about breast cancer reconstruction toward equitable reconstruction access and shared decision-making.